Online Complaint Submission

Please read the following instructions prior to completing the Online Complaint Submission form.

Required Information:
Form fields marked with a red asterisk ' *', are considered required information and must be completed.

Contact Information:
We require your contact information so that we are able to get in touch with you if we need further information.

Complaint Information:
The information you provide in this section will assist us in determining the nature of your complaint. We will require different information depending on the Policy Element selected. From the drop-down menu, select the Policy Element that best describes the type of complaint and complete the remaining fields displayed.

Complaint Details:
Use this section to describe the nature of your complaint as it applies to the Policy Element you have selected. It must include the steps you have taken up until this point.

Note: JavaScript must be enabled for the following form.

BEFORE YOU BEGIN:
Have you completed steps 1 through 3? *	Yes No

MERCHANT INFORMATION
Merchant Name *
Name of person submitting complaint *
Merchant Street Address *
City *
Province / Territory *
Postal Code *
Contact Phone Number * (xxx) xxx-xxxx
Alternate Phone Number (xxx) xxx-xxxx
E-Mail Address *
Name of Acquirer *
Name of Representative at Acquirer / Processor contacted in Step 3 *

COMPLAINT INFORMATION:
Policy Element *

COMPLAINT DETAILS
Please describe below the nature of your complaint. Include as much relevant detail as possible (i.e, dates, names of people you spoke to, access to correspondence in hard copy, your efforts to resolve the complaint, etc.)

CAPTCHA
In order to prevent abuse of the complaint system, please type the 4 characters seen in the image to the right *	Reload Image

Javascript must be enabled.